Patient SatisFICTION?

The director of our group was called to the administrative offices to explain why our Press Ganey scores had dropped eight percentage points. A slightly larger than normal proportion of patients rated us as “good” rather than “excellent” for the past couple of months. Now the hospital wants answers.

It wouldn’t be so bad if the hoops we had to jump through were rationally related to the care that we are providing. They aren’t. The things that are useful measures such as “quality of care” and “medical decisionmaking” are intangibles that can’t be measured and plugged into a spreadsheet. Try it. Describe what “quality care” is and then figure a way to quantify it.
Is quality care adhering to published guidelines? What if there aren’t any guidelines for your patient’s situation?
Does quality care amount to less complications than the other practitioners in your specialty?If so, then a large percentage of physicians will cherry-pick healthy patients who are less likely to suffer complications. What happens to doctors who care for the severely ill patients?
Maybe quality of care is equivalent to low cost. If we use that definition, then we’re going to be creating an incentive for doctors not to order “unnecessary tests” and not to find diseases. The old saying goes “if you don’t go fishing, you won’t catch any fish.”
It is nearly impossible to come up with a quantifiable definition of “quality care.”

So what happens? In some specialties, we allow our worth as physicians to be measured based on data that can be quantified: Our ability to make patients happy. When speaking specifically about emergency medicine, the measurements don’t start there, though. First, the system throws patients into situations that tend to make people mad or frustrated — in need of medical care and forced to wait, sometimes for an excessively long time, with a bunch of other people who are also in need of medical care — THEN we start measuring physician worth.

Sometimes patient happiness isn’t related in any way to the physician’s care, but the staff gets blamed anyway.
There are the creature comfort complaints like “the room was too cold” or “the food was horrible.” Patients may get blankets, but sometimes decreased satisfaction scores still carry over to the provider side of the survey.

Then there’s the “I saw my doctor the next day and he said that you should have given me antibiotics for my cold.” Great. The follow up doc is both a backstabber and an idiot. Doesn’t matter that the patient would have gotten better even if the doctor prescribed soap suds enemas because nothing is going to make a viral infection go away except time. Nevertheless, the physician providing medically appropriate care gets lower marks because of another doctor’s inappropriate medical treatment.

There are other examples, but you get the picture. The best similarity I can come up with is using a ruler to measure how cold it is outside. The instrument you’re using has little bearing on what you’re trying to measure.

Then I did some studying and found out additional information about patient satisfaction surveys in general.

To get an adequate sample size, for 1000 patients, you need about 280 respondents to have a 5% margin of error and you need 400 respondents to have a 1% margin of error. That’s between a 28% response rate and a 40% response rate for statistically valid data. Larger sample sizes need less response rates, but these numbers are just to give a general idea. Know what the response rate for a well-known patient satisfaction survey company is? Between 8% and 10%.

Then there’s the statistical term called “standard deviation.” The bell curve for any data set can vary. If 10% of people taking a test each got grades of 10, 20, 30, 40, 50, 60, 70, 80, 90, and 100, then the bell curve would be very flat and wide like a sprawling hill. If 10% got grades of 45, 80% got grades of 50 and 10% got grades of 55, then the bell curve would be very steep and narrow like the Washington Monument. The steeper that the bell curve, the less variation in the data. Often patient satisfaction data has a very steep and narrow bell curve. Therefore a small change in the data from one facility – such as a few more people than usual rating you as “good” rather than as “excellent” – can have a profound and potentially misleading effect on where your facility falls on the bell curve.

So I’ve decided to create a survey of my own … about the surveys.

Please pass along the link to your friends and colleagues. I’m looking for input from patients, administrators, and health care professionals. The more input, the better the results. There are at most about 20 questions, so it shouldn’t take more than 5 minutes to complete.

18 Responses to “Patient SatisFICTION?”

I filled out your survey. I promise that I was not being sarcastic. I really hate those PG surveys and refuse to fill them out unless my health care provider specifically asks me to do so for them. I find them insulting to the health care provider based on everything you said here. If I’m going to the hospital for lab work or an MRI or because I’m seeking assistance with the birth of a child, I’m doing so because I can’t do these things myself. I’m not looking to make a new best friend with the phlebotomist or L&D nurse. It takes a LOT for me to complain about a health care professional. If there was something that needed to be addressed – even positively, a letter is much more effective than a scantron form entered by a drone who does thousands of those a week.

I agree with what you say about the validity of subjective opinion to arrive at an objective quality of health care.

I don’t they are interested in a ‘truth’ per se, but rather, the suits are interested in trumpeting data that shows how ‘good’ their hospital is… for public relations, etc. So perception is the only thing that really matters, sadly. Whether or not something is true is beside the point.

Moreover, PG and their ilk are basically selling a product (an evaluation tool) to hospitals that is used for marketing, future investment, etc… and that is a business itself!

Funny how we in the ER ..uh ..ED are brutalized by administration when PG’s go bad.

Yet, I have only once taken a satisfaction survey to rate our hospital administration. And, sadly, I was the one who designed and implemented the survey. Suffice to say, the administration did rather poorly. (And it was not a “push survey designed to cast administration in a poor light, but more opened “please comment on” survey). Sadly, I had to resign a month later from that job.

I think the best comment on my survey, when asked about what admin could do to improve was “quit doing surveys and ask one one question of the staff… Would you come here for care? If the staff won’t come here, you have a problem. A management problem”

I can’t imagine how any survey that has an 8% response rate is being used to change policy, reprimand people, etc. I think you should note too, Whitecoat, that admitted patients don’t get the surveys, right? Only patients who weren’t sick enough to be admitted are surveyed.

I answered your survey, but w/nurses at my facility, they tended to focus on one thing like speed of treatment or “door to doctor time” and make us worry about that instead of the whole survey. I can’t say I ever saw raw survey data.

Our yearly “employee engagement survey” usually had a 95% or so response rate :-) People show up en masse to criticize management!!!

I received a PG survey after the birth of each of my kids. My second I was only there about 15 hours, but my first I was there for 3 days. So admitted patients get them, too.

I never did receive one for my mom (I was her POA) when she was admitted with a stroke and then again with emergency abdominal surgery… nor any other time when she was readmitted for a few days/weeks at a time until her death 6 months later.

So maybe only the not-really-sick-just-having-a-baby admitted patients get them?

When only a tiny number of people answer surveys it can really screw you up. My hospital does almost no qualitative review of care. All they know is those surveys.

The one we use is pretty weak. It asks was your physician “satisfactory.” If “yes” it counts as neutral. If “no” patient is encouraged to elaborate. If patient voluntarily elaborates on how great doc was that counts as positive feedback.

It seems skewed to pick up negative feedback. I’ve only had one negative and on that one I know I did perfect care, but the patient had to wait several hours with a broken bone. Sorry but the ER was full.

I’ve never changed care due to feedback issues, but I admit I’ve always got it in the back of my mind since they’ve been known to let ER docs go who had too many negatives.

Yeah, those PG surveys are ridiculous. I have pointed out the statistical reasons behind their worthlessness to our team … everyone gets it, so no one sweats it. Fortunately, the hospital didn’t really care about PG.

They do care about complaints directly to “customer relations” though, as well as any letters-threatening-lawyers.

Interesting to see WC question the usefulness of surveys in this arena, when he relies so heavily on them in other arenas. I agree with his skepticism toward them, it just should be applied across the board.